flowchart TD
A{Crossley et al} --> B(3 months)
A--> C(6 months)
A--> D(12 months)
Kambhampati & Vaishya, 2019
Limitations of previous reviews:
More recent reviews
Comparator limb
Contralateral (uninjured) limb
Pros ✅
Cons ❌
Comparator limb
Pre-injury contralateral limb
Pros ✅
Cons ❌
Comparator limb
Uninured (healthy) control limb
Pros ✅
Cons ❌
requires normalisation & matching (e.g. sex, age)
relevant population data not always available (e.g. sport/activity specific)
introduces biological varaibiltiy to comparisons
Functional Performance
How does muscle strength and funcional performance change over time after ACLR
A group of systematic Reviews with meta analysis
Databases: MEDLINE, EMBASE, CINAHL, Scopus, Cochrane CENTRAL, SPORTDiscus
Inclusion criteria: primary ACL injury, aged 18-40 years, with a quantitative measure of muscle strength or hop performance
Methodological Quality Assessed on domains outlined by Cochrane Collaboration
Comparison:
A group of systematic Reviews with meta analysis
Additional Criteria:
\[\begin{equation} RoM = \frac{90Nm}{100Nm} \end{equation}\]
Example: ACL Side compared to the contralateral side
ROM = 0.9 95%CI[0.85-0.95]
= ACL side is 0.9x weaker than the contralateral side
= 10% deficit in ACL side strength
Longitudinal/multivariate meta-analysis
Ishak et al 2007, Clinical Trials
Trikalinos & Olkin 2012, Clinical Trials
Cheung 2019, Neuropsychol Rev
Mueskiwa et al 2016, PLOS ONE
Longitudinal/multivariate Meta-Analysis
Allow multiple (correlated) pieces of information from the same study to be included in a meta-analysis
flowchart TD
A{Crossley et al} --> B(3 months)
A--> C(6 months)
A--> D(12 months)
“2-Level”
Random effects for
flowchart TD A[Meta-analysis] --> B(Study 1) A--> C(Study 2) B--> D(i) B--> E(iii) B--> F(iii) C--> G(i) C--> H(iii) C--> I(iii)
“3-Level”
Random effects for
flowchart TD A[Meta-analysis] <--> B(Study 1) A<--> C(Study 2) B--> D(T0) B--> E(T6) D--> F(i) D--> G(ii) D--> H(iii) E--> I(i) E--> J(ii) E--> K(iii) C--> L(T0) C--> M(T6) L--> N(i) L--> O(ii) L--> P(iii) M--> Q(i) M--> R(ii) M--> S(iii)
metafor package.Random effects:
(timepoint | cohort)
Fixed effect: timepoint
Robust variance estimation methods using clubSandwich package 🥪
Is comparing to the contralateral limb equivalent to comparing
to uninjured controls
Between-person deficits were 1.53x greater than within person (95%CI 1.15 to 2.19)
Systematic Review with Meta Analysis
Same methodology as reviews thigh muscle strength and hop performance
Inclusion criteria: primary ACL injury at age 18-40 with a quantitative measure of hip or lower leg (calf) strength
Exclusion criteria: No restriction on sample size or publication year
28 studies 🇦🇺 🇬🇧 🇺🇸 🇮🇷 🇯🇵 🇩🇪 🇹🇷 🇧🇷 🇳🇴 🇰🇷
1103 ACL injured (all except 12 reconstructed) + 1145 controls
Mean age ranging from 19 to 38 years
Most timepoints between 7-12 months post ACL surgery
Limited information on activity levels
No consistent or widespread weakness of the hip or calf muscles after ACL injury
Limitations
Low sample size especially for hip IR, flexion, soleus and dorsiflexors
Variability and heterogeneity
Very low certainty evidence